COVID-19: Neurology service guide

Please follow the link below to a validated spread sheet that details the current position of all clinical services at the RD&E. This information is being provided by the RD&E and will be updated weekly.

RD&E Clinical Services Restoration update

August 2020

Scope

This information provides updated guidance on the management of patients with neurological presentations and conditions during the COVID-19 pandemic. The information is based on national guidance from Association of British Neurologists guidance on COVID-19 for people with neurological conditions and and NICE guideline NG127 referral of suspected neurological conditions.

National guidance

Association of British Neurologists guidance on COVID-19 for people with neurological conditions

NICE guideline NG127: referral of suspected neurological conditions

2WW referrals

At this time there will be careful consideration of the prioritisation and management of patients referred on the 2 week wait pathway due to pressure on services. Advice may be given on managing patients without recourse to outpatient attendance.

Conditions with specific guidance

Stroke
  • Urgent stroke clinic referrals: rde-tr.dailystrokeclinic@nhs.net
  • OR call the stroke team administrator for a stroke clinic referral on 01392 402552 if the patient is with the referring clinician.
  • All patients with possible TIA are telephone triaged and some are offered F2F review.
  • Stroke Nurse Practitioner / Front-line stroke consultant or neurologist: 07825 716447

Message from Anthony Hemsley 20/7/20

In response to the coronavirus pandemic and in recognition of the need to support patients, who have sustained an acute stroke, to return home as soon as practicably possible, the Stroke Support Team (SST) service was rapidly expanded to provide coverage to all geographical areas of the Easter Locality. Prior to this, the SST was limited to Exeter, WEB and Tiverton and Cullompton PCNs.

The Stroke Support Team (SST) is a specialist community stroke rehabilitation team comprising nurses / OTs / PTs and Speech and Language therapists. All patients who are discharged from RDE acute with SST have been assessed by the hospital stroke multi-disciplinary team, including the stroke consultants.

At the point that the patient leaves hospital with SST, their primary point of contact for medical issues is their GP. However, we have a robust system for support from the acute stroke service and SST has a named stroke consultant for specialist advice and guidance should they need it.

MS Nursing service

We take direct referrals from GP's for people with a confirmed diagnosis of multiple sclerosis. If the diagnosis is uncertain or the person is new to the RDE MS nursing service a neurology opinion should be sought first.

The direct dial number for the MS nurses is: 01392 208588

The direct dial for the MS coordinator is: 01392 208584

Blood results for out of area MS patients can be sent to the following email: rde-tr.msadminmardon@nhs.net

Information can be gained from the following websites;

Multiple Sclerosis Trust

MS Society

Shift MS Forum

Epilepsy Nurse Service:

I currently take referrals for patients with a diagnosis or under investigation for epilepsy from the Neurology team. I do take direct referrals from the obstetrics and Gynaecology team for ladies who are pregnant with epilepsy or need pre conception counselling. I am unable to currently take direct referrals from GP's but I am happy to give advice, if about medication I will seek consultant support. If a patient has VNS I will also take a direct referral to manage this.

The direct number for the epilepsy nurse telephone line is: 01392 408426 or Kate, as secretary, 01392 404600.

Email:Claire.crudge@nhs.net

I direct patients and GP's to following sites for advice:

https://www.epilepsy.org.uk/

https://www.epilepsysociety.org.uk/

We also have two Learning Disability Epilepsy nurse. Marion Saunders and Karen Herbert. Who are employed by DPT but work alongside us. They are also a point of contact and their referral criteria is the same as mine, but again happy to give advice to health professional. Their emails are:

marionsaunders@nhs.net

k.herbert@nhs.net

Parkinson's Disease Specialist Nurse service:

The community Parkinson's Disease Specialist Nurses are able to support patients and professionals with Parkinson's Disease. For patients moving from out of area, waiting for an outpatient appointment, they can be supported by the service as long as they have a diagnosis of Parkinson's disease made by a consultant.

For Exeter, Okehampton and Crediton GPs contact Ann Gilbert and Claire Soper on: 01392 405477

anngilbert1@nhs.net

Claire.soper@nhs.net

For Mid and East Devon GPs contact Em Baker: 01884 235552 or email em.baker@nhs.net

Out of Hours we all advise patients to seek advice from Parkinson's Uk helpline

Devon Memory Service:

For patients where a new diagnosis of dementia needs to be considered:

The current referral criteria and process for the Devon Memory Service can be accessed through the Devon Formulary:

For atypical / early dementia presentations referral can be made directly to Professor Zeman.

Referral Criteria for Devon Memory Service
  • When deciding to refer to the Memory Clinic the GP should provide the patient with written information on what to expect.
  • Please include the following information in the referral proforma:
  • Cognitive test score (see investigations above)
  • Confirmation that blood tests have been undertaken and attach results if available (see investigations above)
  • Confirmation that a physical examination has been done
  • Any pertinent social factors including the name and contact number of a close family member or carer who is able to attend the Memory Clinic appointment with the patient being referred. This is crucial because assessment at Memory Clinic and dementia diagnosis cannot be undertaken without collateral information being provided by someone who has known the patient for some time, and can therefore reliably report on observed cognitive and/or functional decline
  • That depression and/or anxiety have been checked for and treated where necessary
  • That the possibility of dementia has been discussed with the patient and carer/family member where possible

For help with behavioural and psychological symptoms of dementia:

The Devon Memory Service is a diagnostic service – if the patient already has a diagnosis of dementia then referral for difficulties with behavioural and psychological symptoms of dementia should be made to the patient's local Community Mental Health Team, or for general support to the Alzheimer's Society Dementia Support Workers 0300 123 2029, devon@alzheimers.org.uk

The University of Exeter-led IDEAL programme has also produced advice and leaflets which may be of help:

See 'Five tips from project to support people with dementia and carers in COVID-19 lockdown

The two leaflets containing the five key messages are available to download at Ideal Project

Leaflet for people living with dementia

Leaflet for carers of people living with dementia

Functional neurological symptoms/disorders clinic

The FNS service was established in response to a high demand for input for patients with functional neurological symptoms. We provide advice, assessment, consultation and intervention for patients suffering with FNS where they have gone through a thorough diagnostic process with Neurology and when any co-existing mental health symptoms are being managed. Please see our referral criteria below to guide decision making:

Inclusion Criteria - We are open to referrals for assessment when a community patient:

  • Is 18 years old or above
  • Has one or more functional neurological symptoms
  • Has been diagnosed with functional neurological disorder (FND/FNS) by a Neurologist
  • Have completed all diagnostics
  • Have been informed of the functional diagnosis Has agreed to a referral to the FNS team to see a Psychologist
  • Has a GP within Exeter, East Devon and Mid Devon Localities*

Exclusion Criteria - We are unable to provide an assessment and intervention service for patients:

  • Who are awaiting test results
  • Who are pursuing further diagnostics
  • With a primary unmanaged mental health presentation:
    • Presenting with dissociation or personality changes not characterised by apparent seizure activity or functional symptoms
    • Whose functional symptoms occur in the context of an unmanaged mental health condition e.g. Emotionally Unstable Personality Disorder, PTSD, or Borderline Personality Disorder.
  • Who are currently excessively using alcohol or illicit substances
  • Who are unwilling for us to liaise with health colleagues across the RD&E and DPT where it is appropriate.

In regard to patients subject to exclusion criteria, we are happy to provide an advice and consultation service for clinicians working with those patients. The aim is to support colleagues to practice in FNS-informed ways and to enable a realistic care-pathway to be established to enable recovery or better management of symptoms.

If you would like to discuss this further or have any questions or concerns then please feel free to contact me on the above number or at leo.russell@nhs.net.

*GP Surgeries within Catchment Area

  • Amicus Health
  • Axminster Medical Practice
  • Barnfield Hill Surgery
  • Bow Medical Practice
  • Bramblehaies Surgery
  • Budleigh Salterton Medical Practice
  • Castle Place Practice
  • Chagford Health Centre
  • Cheriton Bishop Surgery
  • Chiddenbrook Surgery
  • Claremont Medical Practice
  • College & Sampford Peverell
  • Cranbrook Medical Practice
  • Haldon House Surgery
  • Hatherleigh Medical Centre
  • Hill Barton Surgery
  • Honiton Surgery
  • Ide Lane Surgery
  • Imperial Surgery
  • Isca Medical Practice
  • Mid Devon Medical Practice
  • Moretonhampstead Health Centre
  • Mount Pleasant Health Centre
  • New Valley Practice
  • Okehampton Medical Centre
  • Pinhoe Surgery
  • Raleigh Surgery
  • Rolle Medical Partnership
  • Seaton & Colyton Medical Practice
  • Sid Valley Practice
  • Southernhay House Surgery
  • St Leonards Medical Practice
  • St Thomas Health Centre
  • The Blackdown Practice
  • The Clock Tower Surgery
  • The Coleridge Medical Centre
  • The Foxhayes Practice
  • The Heavitree Practice
  • The South Lawn Medical Practice
  • The Whipton Surgery
  • Topsham Surgery
  • Townsend House Medical Centre
  • Westbank Practice
  • Wonford Green Surgery
  • Woodbury Surgery
  • Wyndham House Surgery

Botulinum Toxin Clinic

For cases where there is clear need for botulinum toxin Dr Harrower is happy to receive these referrals directly - this includes all potential spasticity patients, dystonia patients, sialorrhoea, chronic migraine, blepharospasm, hemifacial spasm, Tourette syndrome. For chronic migraine please check the NICE criteria for this treatment – patients need to have tried three preventatives adequately, not have rebound headache and have headache days for the majority of the month, the majority migrainous. The completion of a headache diary aids this assessment.

Huntingdon's Disease

Patient's with Huntingdon's disease may be referred directly to Dr Harrower.

Motor Neurone Disease

For new patients with suspected motor neurone disease, where there is clinical concern, the MND care network co-ordinator Tracy Thomas (see contact details below) is happy to help coordinate a clinic appointment. For patients with established diagnosis Tracy and the MDT are happy to be contacted directly.

Tracy Thomas

Lead Clinical Nurse/Care Network Co-ordinator, Motor Neurone Disease Peninsula Network

Dept of Neurology Level 10, Derriford Hospital, Derriford Road, Plymouth PL6 8DH

  • Office phone - 01752 436759

The Motor Neurone Disease Association is a great source of information and support to patients, carers and professionals:

Motor Neurone Disease Association

email: mndconnect@mndassociation.org

MND Connect Helpline 0808 802 6262

Headache

The Exeter Headache clinic are currently offering a video service and have a current waiting list of six months.

We are happy to offer advice to GPs, either by email or telephone.

As we are unable to examine patients at this time, we would be grateful if you could include details of fundoscopy and blood pressure as the minimum examination parameters in your referral. All consultations will be via secure video link.

However, the team are happy to give advice to health professionals either by email or telephone. A migraine self-management handbook is available via the Exeter Headache Clinic website.

Email: sam.hotton@nhs.net or Telephone: 01392 676679

The Neurology team continue to support the management of patients with atypical or treatment resistant headache either by advice and guidance or in clinic. It is always helpful for the referral letter to include a full history of treatments tried to date in such cases.

Sleep Disorder

For sleep disorder (excluding suspected obstructive apnoea) investigation and management refer directly to Professor Zemam sleep clinic.

For insomnia please check criteria below and then referral can be made to Professor Zeman or Miss Stephanie Romiszewski - Specialist Sleep Physiologist.

a. predominant complaint of dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:

1. Difficulty initiating sleep.

2. Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings.

3. Early-morning awakening with inability to return to sleep.

b. The sleep difficulty is present for at least 3 months.

c. The sleep disturbance causes clinically significant distress or impairment in social, occupational, educational, academic, behavioral, or other important areas of functioning

d. The sleep difficulty occurs at least 3 nights per week

e. The sleep difficulty occurs despite adequate opportunity for sleep.

f. The insomnia is not better explained by and does not occur exclusively during the course of another sleep-wake disorder (e.g., narcolepsy, a breathing-related sleep disorder, a circadian rhythm sleep-wake disorder, a parasomnia).

g. Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia.

h. The insomnia is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication).

See links for patient information leaflets on narcolepsy, sleep hygiene and insomnia.

Miss Stephanie Romiszewski - Specialist Sleep Physiologist

Neurology - Mardon Rehabilitation Centre

Royal Devon and Exeter Hospital

Exeter, Devon EX2 4UD

Tel: 01392208583

Email: s.romiszewski@nhs.net

Rehabilitation

For the Exeter area, community rehabilitation team is based at Whipton Hospital. Referrals to this service are made via the usual referral route.

Please see link to Eastern area community rehabilitation contacts.

Exeter Community Rehabilitation Service

Budlake Centre, Exeter Community Hospital (Whipton)

Hospital Lane, Exeter, EX1 3RB

Tel: 01392 208342

Email: rde-tr.whiptonreablement@nhs.net

Enquiries re suitability of patients for input from the specialist neuro-rehabilitation team at the Mardon should be directed to Dr Rachel Botell.

Mardon Rehabilitation Centre

Royal Devon and Exeter Hospital

Exeter, Devon EX2 4UD

Tel: 01392208583

Urgent referrals

Utilise standard pathways, referrals continue to be triaged.

Routine referrals

Utilise routine pathways.

Urgent advice

Contact switchboard Tel: 01392 411611 and request to contact neurologist on rota for telephone advice during working hours. Outside of 9-5 ask to be connected to the neurologist of the week

Advice & Guidance/Telemedicine services

Electronic Advice and Guidance service remains available Monday to Friday via usual portal. In addition during pandemic (this will be provided until the end of July) a 9-5 consultant telephone advisory service is provided. To access this contact switchboard Tel: 01392 411611and ask to be connected to neurologist on rota for telephone advice.

Covid 19 High risk patient advice

The neurology service is functioning to support social distancing to minimise risk to patients, their carers, medical staff and the population as a whole. We are particularly concerned to minimise COVID-19 risk to vulnerable patients already under our care and patients at the point of referral. This especially applies to older more frail patients, patients with conditions affecting their breathing or swallowing, patients with dampened immunity (either from their condition or immunosuppressive treatment), and patients with multiple morbidity.

We have moved most of our outpatient clinic provision off-site to the Nuffield Hospital on Wonford road. Patients should feel safe to attend this facility where a number of measures are taken to minimise COVID-19 risk; spacing is ensured in the waiting room – patients are asked to wait in their car (if this is how they arrive) and called in on their mobile to maintain low patient density in the waiting area, all staff and patients have a temperature check entering the building.

Some patients will be seen in outpatients in the main RD&E building. There has been very significant reduction in throughput here to ensure that adequate distancing is maintained in the waiting areas.

Where risk of coming to hospital is felt to be excessive, we are offering telephone consultations for follow up and some new patients.

Patients at high risk from COVID-19 will have been contacted. Appropriate advice regarding shielding and social distancing will have been given, according to national policy and taking into account patient's individual risk profile.

The latest national advice on shielding is being communicated to high risk patients as follows (there are 2 stages of step down coming into force on the 6th of July and the 4th of August, the first step down is still referred to as 'shielding');

The Government's current guidance is that you are strongly advised to stay at home as much as possible and keep visits outside to a minimum (for instance once per day). You are advised to follow the shielding guidance rigorously. You may, if you wish, spend some time outdoors, but you should maintain social distancing at all times, wash your hands regularly with soap and water or hand sanitiser and avoid gatherings of any size. These measures, referred to as 'shielding', will help protect you by reducing the risk of you coming into contact with the virus. The current guidance can be found online at GOV.UK.

This advice is provided by the Government for your personal protection and it's your choice to decide whether to follow these measures.

The latest scientific evidence shows that the prevalence of disease across all English regions has dropped substantially since the peak of the virus in April. If this trend continues as it is expected to, the Government will relax its shielding advice in two stages on 6 July and 1 August.

From 6 July:

  • you may, if you wish, meet in a group of up to 6 people outdoors, including people from different households, while maintaining strict social distancing;
  • you no longer need to observe social distancing with other members of your household; f
  • or single adult households (either an adult living alone or with dependent children under 18) in the general population, you may, if you wish, also form a 'support bubble' with one other household. All those in a support bubble will be able to spend time together inside each other's homes, including overnight, without needing to socially distance.

From 1 August the advice to 'shield' will be paused. From this date, the Government is advising you to adopt strict social distancing rather than full shielding measures. Strict social distancing means you may wish to go out to more places and see more people, but you should take particular care to minimise contact with others outside your household or support bubble.

In practice, this means from 1 August:

  • you can go to work, if you cannot work from home, as long as the business is COVID-safe;
  • children who have been identified as at high risk from coronavirus can return to their education settings if they are eligible and in line with their peers. Where possible children should practise frequent hand washing and social distancing;
  • you can go outside to buy food, to places of worship and for exercise, but you should maintain strict social distancing; and
  • you should remain cautious as you are still at risk of severe illness if you catch Coronavirus, so the advice is to stay at home where possible and, if you do go out, follow strict social distancing.

More detailed guidance will appear on GOV.UK when the changes come into effect on 6 July and 1 August.

After 1 August your name will continue to be kept on the list of individuals considered at highest risk. The Government will continue to monitor the virus over coming months and if it spreads too much, you may be advised to shield again.

Support to stay at home

Up until the 31 July, the Government is providing support to those at highest clinical risk in need, including food, care and free delivery of medicines.

You can register for this until 17 July at GOV.UK or by calling 0800 028 8327; to allow support to reach you whilst you are advised to shield. You'll be asked for your NHS number in order to register, which you can find at the top of this letter.

The Government is helping pharmacies to deliver prescriptions until the end of July. Prescriptions will continue to cover the same length of time as usual. If you do not currently have your prescriptions collected or delivered, you can arrange this by:

1. Asking someone who can pick up your prescription from the local pharmacy, (this is the best option, if possible);

2. Contacting your pharmacy to ask them to help you find a volunteer (who will have been ID checked) or deliver it to you

You may also need to arrange for collection or delivery of hospital specialist medication that is prescribed to you by your hospital care team.

Local councils have also been providing support to those shielding. This has included a wide range of help to enable you to safely stay in your home, such as phone calls to reduce loneliness and meeting special dietary requirements. In order to help people adjust, local councils will continue to provide these services to those who need them until the end of July.

If you are struggling as a result of Coronavirus please visit GOV.UK - Coronovirus-support to get information on the range of support options available. If you need urgent help and have no other support, please contact your local council.

NHS volunteer responders

If you do not have anyone who can support you, NHS Volunteer Responders are here for you. This support will continue beyond the end of July. NHS Volunteer Responders can support you with:

  • collecting shopping, medication (if your friends and family cannot collect them for you) or other essential supplies;
  • a regular, friendly phone call which can be provided by different volunteers each time or by someone who is also shielding and will stay in contact for several weeks; and
  • transport to medical appointments.

Please call 0808 196 3646 between 8am and 8pm to arrange support or speak to your health care professional for transport support. More information is available at national volunteer responders

Going to work

This letter is evidence, for your employer, to show that you cannot work outside the home until 1 August, including for statutory sick pay purposes. You do not need to get a fit note from your GP. If you need help from the benefit system visit GOV.UK -Universal credit

You should discuss your situation with your employer and agree a plan for returning to work from 1 August if you cannot work from home. Your employer may need to make adjustments to help you continue to work. Please go to GOV.UK Access to work for more information.

Accessing NHS services

You should continue to access the essential services that you need, and you should contact the NHS if you have an urgent or emergency care need.

If you have ongoing appointments scheduled for care and treatment your GP surgery or hospital clinic will contact you to confirm the most appropriate arrangements.

If you have any of the symptoms of coronavirus (COVID-19) (a new continuous cough, a high temperature, or a loss of, or change in, your sense of taste or smell), you must self-isolate at home and arrange to have a test to see if you have COVID-19 – go to the NHS website to arrange a test or contact NHS 119 via telephone if you do not have internet access.

Condition Specific Advice in relation to COVID-19

MS

  • Many patients with Multiple Sclerosis are on immunomodulatory treatment. Their treatments and vulnerability will vary and will have been considered according to ABN guidance and plan communicated via the MS specialist nurse team. In most cases treatment is continuing.
  • Specialist Nurse support continues

Parkinson's Disease

  • Many patients with Parkinson's disease are frail, have comorbidity or have impaired swallowing. These patients are advised to maintain shielding according to national guidance and should still be vigilant to maintain social distancing as they come out of shielding.
  • Specialist Nurse Support Continues

Neuromuscular disease (mostly this is patients with Myasthenia Gravis and motor neurone disease)

  • Patients with a recent history of breathing, swallowing or speech difficulties should be considered high risk and continue to shield according to national guidance and maintain vigilance with social distancing as they come out of shielding.
  • Patients on azathioprine are considered high risk and should shield as per national guidance and maintain caution coming out of shielding.
  • Patients on prednisolone greater than 20mg or steroid sparing drug + prednisolone greater than 10mg are also high risk and should maintain caution.

Neuropathy

  • Most patients with neuropathy are not at increased risk from COVID.
  • Patients on immunomodulatory treatments may be at risk and will have had their risk status considered.

Muscular Disease – myositis, muscular dystrophy

  • In many instances such patients have weak cough, swallow compromise, mobility compromise or cardiac pathology. As such they may be high risk and should continue to follow national advice.

Epilepsy

  • Generally, patients with uncomplicated epilepsy are not at increased risk from COVID-19.
  • Patients referred with first seizure may be offered a telephone consultation at this time.

Medical/immunosuppression treatment for neurology patients without symptoms of COVID-19 infection

  • People with neurological conditions should not stop or alter their medication without prior discussion with their neurology team.
  • The risk/ benefit of continuing or pausing on-going treatment is being considered on a case by case basis. In many cases the risk of stopping treatment exceeds the risk posed by COVID-19 and continuation of treatment.
  • Please follow this link for additional information: The Neurological Alliance

Neurology contact information

Neurology Team

9am - 5pm, the Neurology Team can be contacted via neurology secretaries:

Exeter: 01392 408730

North Devon: 01271 311585

For out of hours urgent advice, the on-call consultant can be contacted via hospital switchboards:

Exeter 01392: 411611

North Devon: 01271 322577

Supporting Information

Contacts for supporting third sector organisations are listed under condition specific guidance.

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group

Publication date: July 2020

Date updated: September 2020

Last updated: 04-06-2021

 

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